Open Dialogue

I went to a conference in Nottingham yesterday to learn about a technique called Open Dialogue. I wanted to know more because of how it has revolutionised the care of people who are in crisis in parts of Finland and the US, reducing demand on mental hospitals and transforming lives.

I care deeply about mental health services, although I don’t run them any more. These days I campaign to make them better. I volunteer in suicide prevention. I chair the Time to Change mental health professionals project. And sometimes I need help from services myself.

I wish you could have been there too. Some massive pennies dropped, not just for me but for everyone who hadn’t already appreciated the possibilities. We learned that Open Dialogue is about being with people rather than doing something to them. And we realised that here was a way to mend things that previously seemed unfixable.

Let me explain.

There are some who say that the NHS is broken. And that mental health services are badly broken.

I’m not sure that broken is a helpful way to describe things. I prefer to think of them as badly wounded. And when someone is wounded, you take care of them.

I believe that people in highly influential positions do care about mental health. They are just unsure about what to to do, other than saying they care. They know that mental health services around the country are buckling under the strain of increasing demand. Referral rates have never been higher. And continue to climb. Services find it increasingly difficult to discharge people because there is nowhere for them to go. Staff are overwhelmed, and there is a growing recruitment and morale crisis.

Added to which, successive governments say one thing about the importance of mental health but allow the opposite to happen regarding funding. Despite the fine words and promises in the response to the Mental Health Taskforce report published in February, we heard just a few weeks ago from NHS Providers that mental health trusts are not seeing the promised investment and some are reporting funding cuts in 2016 – 2017. Parity of esteem? Actions speak louder than words.

How might Open Dialogue help?

Firstly, it isn’t simply a technique for listening really carefully to people who experience trauma and distress AND their families so that together they can work out their own solutions, with support. It is also an extremely respectful way for people to relate to one another, in teams, across teams, organisations, health care systems and society. Even the NHS.

Secondly, Open Dialogue is the antidote to what is sometimes called the biomedical model, when doctor knows best and patients are compliant. This works when there is a fairly simple problem and solution. For example, a broken leg. It doesn’t work for the vast majority of health conditions in which people need to become the expert themselves if they are to lead fulfilling lives. And it certainly doesn’t work in mental health. Mental health professionals know this. But we organise and regulate mental health services as though we were fixing broken minds instead of legs.

Open Dialogue builds on what some call the Recovery Model, based on hope and fulfilment rather than simply diagnosis and treatment. It provides a method to apply a recovery-based approach, involving the whole family and team. It is the antidote to outpatient clinics and ward rounds.

Thirdly, Open Dialogue provides the basis from which to challenge many of the perverse incentives and restrictive practices that have grown up in mental health care out of fear of incident, media criticism or what a regulator might say. Such as staff spending more time documenting care than in giving care. The absolute adherence to risk assessment even though successive independent investigations show it to have limited predictive value. And risk management, which taken to extremes means that those who might possibly pose a risk to themselves or others, are cared for in inhumane conditions with no privacy or dignity, no sheets, cutlery, shoelaces, phone chargers or indeed any other item that someone somewhere has said might pose a risk. And yet we know that ligatures and weapons can be fashioned from almost anything. And that people who are ill, frightened and alone can be driven to do increasingly desperate things. The greatest risk management tool available is compassionate, skilled attention. Open Dialogue offers high quantities of that.

Open Dialogue is being used in a growing number of services in the UK. A research bid has been submitted and passed the first round of scrutiny. If successful, it will explore human, clinical and cost effectiveness, as well as developing a model that is scalable and sensitive to local circumstances.

And to Corrine Hendy, who I first met at an NHS England event about putting patients first last year: Your journey from being locked in a mental hospital to becoming a skilled mental health professional, public speaker and highly effective advocate for Open Dialogue, is more inspirational than any you will hear on X-Factor. I want to repay the inspiration you have selflessly given.